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Chest Pain Relief by Nitroglycerin Does Not Predict Active Coronary Artery Disease

Charles A. Henrikson, MD, MPH; Eric E. Howell, MD; David E. Bush, MD; J. Shawn Miles, MD; Glenn R. Meininger, MD; Tracy Friedlander; Andrew C. Bushnell, MD; and Nisha Chandra-Strobos, MD
[+] Article and Author Information

From Johns Hopkins Bayview Medical Center, Baltimore, Maryland.


Acknowledgments: The authors thank Edward Bessman, MD, for administrative support; Johann Brandes, MD, for assistance with patient follow-up; and Angel Sampedro for assistance with data analysis.

Grant Support: By a National Heart, Lung and Blood Institute Training grant #T32-HLO7227-26 (Dr. Henrikson).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Nisha Chandra-Strobos, MD, Division of Cardiology, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224; e-mail, nchandra@jhmi.edu.

Current Author Addresses: Drs. Henrikson, Miles, and Meininger: Division of Cardiology, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21205.

Dr. Howell: Divison of General Internal Medicine, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224.

Drs. Bush, Chandra-Strobos, and Ms. Friedlander: Division of Cardiology, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224.

Dr. Bushnell: Division of Emergency Medicine, University of Vermont, 111 Colchester Ave., Burlington, VT 05401.

Author Contributions: Conception and design: C.A. Henrikson, E.E. Howell, D.E. Bush, N. Chandra-Strobos.

Analysis and interpretation of the data: C.A. Henrikson, E.E. Howell, D.E. Bush, N. Chandra-Strobos.

Drafting of the article: C.A. Henrikson.

Critical revision of the article for important intellectual content: C.A. Henrikson, E.E. Howell, D.E. Bush, J.S. Miles, G.R. Meininger, T. Friedlander, A.C. Bushnell, N. Chandra-Strobos.

Final approval of the article: C.A. Henrikson, E.E. Howell, D.E. Bush, J.S. Miles, G.R. Meininger, T. Friedlander, A.C. Bushnell, N. Chandra-Strobos.

Provision of study materials or patients: E.E. Howell, A.C. Bushnell, N. Chandra-Strobos.

Statistical expertise: C.A. Henrikson, D.E. Bush.

Administrative, technical, or logistic support: N. Chandra-Strobos.

Collection and assembly of data: C.A. Henrikson, E.E. Howell, J.S. Miles, G.R. Meininger, T. Friedlander, A.C. Bushnell.


Ann Intern Med. 2003;139(12):979-986. doi:10.7326/0003-4819-139-12-200312160-00007
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Our data demonstrate that chest pain relief with nitroglycerin does not accurately predict active CAD in a general population presenting to an emergency department and should therefore not be used as a triage tool. The sensitivity and specificity of this therapeutic response were low both in the overall study sample and in the prespecified subgroup analyses, including patients with known CAD (Figure 2, top). Both the positive and negative likelihood ratios were close to 1.0, indicating that chest pain relief by nitroglycerin is not useful as a diagnostic test (Figure 2, bottom). In addition, the ROC curves demonstrated that alternative definitions of chest pain relief do not improve the diagnostic performance of nitroglycerin.

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Figures

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Figure 1.
Patient enrollment and study flowchart.

CAD = coronary artery disease.

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Figure 2.
Predictive value and likelihood ratios of chest pain relief by nitroglycerin for active coronary artery disease (CAD).Top.Bottom.leftright

The sensitivity and specificity of chest pain relief by nitroglycerin for the presence of active CAD are low both in the overall study sample and in the prespecified subgroup analyses. The 95% CIs for both the positive ( ) and the negative ( ) likelihood ratios for the response of chest pain to nitroglycerin include 1.0, indicating that this test has no statistically significant diagnostic value in both the overall study sample and in the prespecified subgroup analyses.

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Figure 3.
Receiver-operating characteristic curves for chest pain relief by nitroglycerin and active coronary artery disease.pain relieftopbottomtopbottom

Two series of sensitivities and specificities were calculated by varying the decrease in pain intensity defined as : Pain relief is considered as a percentage reduction in pain intensity ( ) and as an absolute reduction in pain intensity ( ). Both curves closely approximate a likelihood ratio of 1.0, indicating that, independent of cutoff, chest pain relief by nitroglycerin has no statistically significant diagnostic value. Representative points are labeled on the receiver-operating characteristic curves, including 50% and 100% pain reduction ( ) and 2.0-unit and 5.0-unit reduction ( ).

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Summary for Patients

Does Chest Pain Relief with Nitroglycerin Mean Coronary Artery Disease?

The summary below is from the full report titled “Chest Pain Relief by Nitroglycerin Does Not Predict Active Coronary Artery Disease.” It is in the 16 December 2003 issue of Annals of Internal Medicine (volume 139, pages 979-986). The authors are C.A. Henrikson, E.E. Howell, D.E. Bush, J.S. Miles, G.R. Meininger, T. Friedlander, A.C. Bushnell, and N. Chandra-Strobos.

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